Home Forums Discussions General Discussion Google Launches Medical Records App

You mentioned something on this subject before? I thought you were an advocate for PHR? If so I would like to hear your thoughts on the value of a PHR for a patient who has an EMR available from the Primary Care that they see. I have often taken a shot at the PHR saying that a patient trying to use one is somewhat analogous to a person arriving at the IRS for an audit, armed with a shoe box full of receipts. My point being that I believe the patient needs a physician to organize and prioritize the record. Greg Pecchia, D.O. speaking to the Calif. state Osteopathic association made the point that "we are becoming medical accountants". I agree with that notion, and believe it is very good to have a competent 'accountant' to put your medical record in order. I don't want to do it for free, but feel it is included in the work I do when I create the database that is the EMR in my office.
My question for you is, when should I put that shoebox in order? Who will pay me to do it. Will I have to put it back in order every time I see the patient? If I peek in the shoebox, but don't put it in order do I incur liability for what is in there? (I think I do!) What if I miss something in the shoebox? Do I incur liability if I decline to look in there? (I think I do incur legal liability for not looking and I think there is a moral imperative to look).
In my dream world my EMR and the shoebox would be able to talk to each other. I could plug in the flash drive or log on to Google and give the patients pass word and then ONLY the new entries would arrive IN MY CHART for me to review and sign off on. My world would remain orderly, the patient would get the advice I can offer and I would have the benefit of the most complete database.
Make me feel warm and fuzzy about these things. Right now I dread the patient handing me a flash drive or a web address for Kaiser when have a waiting room full.

DocM,
You raise some very good points here. I'm especially drawn to your liability questions as well as your concern about how and who will pay you. People are just increasingly come to think of you folks as being for free or at a high discount. But I also wonder about if such concepts even as yours comes about we have a few patients who would load us up with stuff to be review and possibly included every day.

We have one patient who I am just dying to send her "the letter, the 30 day letter that is" that she was faxing us her home sugar blood test all the time and she was complaining about her numbers and her lack of control, but most if not all of it was her lack of diet control. For a brief while she "got religion" if you know what I mean and her numbers were great, Nancy was cutting back on her meds, she was dropping weight and even starting to regain her mobility and gait (she walks with a cane). But in the end her pasta and other eating habits won over her health even in the face of all the obvious positive results. But while she was going back down hill she was sending us all sorts of stuff and asking lots of questions and demanding our doctors time for free on the phone to help her understand what her numbers meant. Now she is on a tight budget and fixed income, but hey when my wife is not even worth a lousy $5 co-pay with her managed medicare plan (I know she actually had the gall to bitch about it!) and she expects lots of "free" counseling and time is just unreal.

Check this out, recently our Aetna reps approached our PO that Nancy belongs to. They are being sooooo generous and so big, they are willing to pay a whole like $20-$30 dollars for "E" visits (at least half the rate of a level 3 around here with this carrier) that go thru a system that allows them to read the entire transcipt and I'm sure save it to their servers and databases to be used against you later in a court of law (No CCHIT here, "E" is full or pit falls).

So I asked them and I paraphrase here, "So if you are willing to pay for on-line email visits, you know frequently the patients don't even know what is important to report, or what to be looking out for. I can see my wife wanting and needing to ask a bunch of follow up questions that would take most of a day or two to do in a back and forth banter on line especially since she can't just sit by her email account and wait all day just to see if she got a reply from a patient or two. So would you folks finally be willing to pay close to if not even more since it is so difficult to Diagnosis over the net or over the phone, for real "phone" visits so the doc can ask lots of questions, perhaps even have the patient look down their own throat, send a digital pic via secure email and the like and hopefully really get to the bottom of the problem???" Of course the rep balked and stumbled all over herself and couldn't ever reply to such common sense logic.

And with email visits too just as you asked above, are we liable for not reading and responding to our email? Who is to judge when a patient is just being a pain verses what is real? One could probably never leave the office at night without responding to each and every email just because.... Sorry but no thanks. If it is that important to you then you can call and come in for an appointment to see my wife and pay her properly for her time and her hard learned expertise....

Patients are frequently terrible self-reporters and just how many right calls and good catches do you make by just being able to see the patients eyes skin tone, smell of their breath or body, tone of their voice? You just can't replace the face to face human interaction that comes from actually seeing and talking. But of course if Aetna can use this to start getting office notes on all the docs in town all without every having a valid reason to make a real chart request hey watch out, because here they come! And they get to pay you at least half of what they would have paid you had the patient come in even for a basic level 3 cold, strep throat visit, no less if it really was a level 4.....

Not to beat on you or a dead horse, but these are the exact type of cases (like the lady above) that I think of when I challenge P4P, you can teach, coach, beg and beat them but in the end, you just can't make any horse drink. But in a small visit once a month at best now you the doctors are responsible for all that happens and the choices these folks make every day in and out in their day to day lives. These are supposedly grown adults who are free willed to pick and choose cigarette smoking, diet and eating habits, whether or not to exercise; citizens of a supposedly free society??? But now they will use this as just another means to reduce your pay and spy on your office notes and compile lots of data on you and your patients.

I like almost even love some of your ideas for a new and improved medical records I really do. You have that vision thing that is so creative, insightful and important, it is how great new concepts come about. But like I said in earlier posts, first we need a guiding set of ethical principles for the use and access to any of this which we haven't even begun to have yet while we race at 100 mph to this finish line. And two I think that this all should still be housed at the docs office and their privately know and held off-site back up facility. The EMR should still be for the most part a better and improved version the old fashioned paper chart. Private and protected by the doc whose ethics are certainly better than any gov't office or software executive.

Lastly, personal flashdrives on keychains so one can always have their records, we could even update them at every visit. Now we the patient whose record it is, is responsible for the protection of the sharing, it is in their hands. And best of all if there is a security breach it is only for one person or one family, not half the country. As my Quest tech said to me today while discussing security options, he said, what is the real chance that of all the places in the country some hacker is really going to want to get into your solo practice's office? And if he is any good at all, no amount of whatever you do is going to keep a real pro out anyway. We are just keeping out the amatuers knowing that the pros are going for the big fish anyway.

Paul that post should get you credit for 2 or 3! Agree with most of it, but I kind of had to skim some parts. Look forward to buying you a beer in Branson and letting you vent a bit.

Doc,
Thanks. Now you know why I assessed Adam the 2 and 10 the other day... "I make posts the old fashioned way, I eeeearrrrn them..."
Nancy and I still have to try and find the funds for this trip. She feels that I should really go for all the tech and shop stuff and yet I really want her to go so she can hang out with some of the Mega Charters and get better day to day use out of this tool she has....

So how much does CMS really think they are over paying us for all this CCHIT??? Oh right about 10.5% too much! Have a great night yourself....

DocM, I do not ADVOCATE either. I am a technologist. I posted this topic as information. I'm not sure that the EMR or the PHR are mutually exclusive.

When I see a specialist, the data he/she produces is usually not transferable to my primary care physician. Remember I said DATA.

This is fraught with concerns, and liability issues. The biggest for me is the ability to maintain the integrity of the data over several interations. For example let's say a specialists enters some information in the PHR. The primary acts on that information. The specialist discovers he/she entered incorrect info, and corrects it. How does the primary care specilist know that the original values they got were wrong?

Can the patient "change" the values in his/her PHR? Like you I have a ton of questions...either way, this is coming and we need to figure out what "this" is!

G & DocM,
G makes good points. But that is why I say what we need to do is have the basic academic and medical review board discussions first and foremost. Let's slow down here, and insist that just like stem cells and cloning that we first, STOP, look and hash out these larger than life issues of privacy and civil libertys first. Then and only then as we start to reach a common sense and eithical point of common ground and understanding, then we can begin to re-start this whole thing and move smarter and safely towards this brave new world.

Unfortunately we have this discussion being driven by folks with much less than perfect motives here. Mainly our own gov't and the private interests of both the carriers and the enterprise based software vendors. That has got to change and we people of good conscience must speak up together and let our concerns be heard.

What I really want to know is where are all our Med Schools, Medical Ethisists, Consitutional Law Scholars and other academics and their institutions? Why are we not hearing from the learned people in this community about the ethical and legal pit falls of all this big brother CCHIT? They are frightening MIA and quiet in these very trecherous times.... Where are any and all of them, wher are they all hiding???

Good Night and Good Luck,
Paul

G. I didn't mean to use the word Advocate like a label or an insult. When I look back at the post I see it that way, but didn't mean it. I was trying to aim the question directly at you as someone with a knowledgeable opinion, and that is what I am happy to hear, your thoughts on the matter. And forgive my ignorance for while I have opinions of my own I am woefully short of knowledge in this technology. to wit: "Data" do you mean specifically all the little 1's and 0's or what I traditionally would call data, IE: the K = 3.9 ?

If you mean the latter, then an error should be handled by everyone the same way. It is an addendum, no white out or erasures allowed in a medical record. And when it is handled in that manner then the addendum has a high priority for all to review who would be affected. In a practical sense this is why I am an advocate of the patient having ONE primary care physician who is responsible for the whole patient and all of the care. Anyone with multiple treating physicians has ALWAYS been (IMO) at great risk of injury from competing treatment strategies (and egos).

But if it is the ones and zeros that are gonna get us in trouble then I need you to tell me more. Does the integrity of the data degrade with multiple viewers? Being copied from multiple sources? I know that isn't what you mean, but I have a feeling you are talking about something that I have never suspected.

DocMartin...by data I mean the physicans work product such as K=3.9.

I agree with what you posted about the sanctity of each data item. The system should not allow the data to be changed. The system must also TIMESTAMP every entry.

The integrity of the data does degrade as a function of the number of times it is copied, depending on HOW it is copied.

These systems have to work in such a way that once an entry is SAVED it is carved in stone, and any edits/updated and carved in stone also. The systems need to ALWAYS SHOW the HISTORY of the entries, specifically because physicians may take an action depending on what was in the system at 12:00am as opposed to what was entered at 8:00am.

While I see the value in the Unitary Responsible Physician, my concern is that it creates a GATEKEEPER to my records, requiring me to have "go to" my PCP everytime I need to share my medical information. Additionally it places a new burden on the PCP to have that information available WHEN I NEED IT, be it in case of an emergency or any other time.

G- There are truly some swords here that cut both ways. The patient is better served by a database that is available 24-7, and the PCP will be off the hook if the patient chooses Google or Microsoft to store this big shoe box full of stuff. I still think the patient is better served when the ER doctor tracks me down and we talk one on one, with me having access to the record. It will make my call schedule harder if I can only trade call with my partners who have access to my practice.
X-M radio had a spokesman for MS touting the benefits of their product. I can't imagine people wanting to hand Bill Gates a copy of there Personal medical record.
Without the protections you describe, carving the date stamp in stone, I will not be anxious to peek into these records.

What about my personal medical history flash drives? No more big brother needed. I like this option much better. And then even the EMS guy could be able to open it up in the field lets say if he needed to, maybe even be able to upload it to the ER while you were in transit... Hey with MS home server, why not have something at your own home? If you have everyone's data spread out behind their own routers and security packages, it would be pretty hard for anyone with mal-intent to compile it all together and use it against any and all of us.

We should all be scared as hell of centralized servers with all our medical info on it. Here is one of my biggest pet peeves. I can not tell you how many times a patient goes to the ER or prompt care place, especially Nancy's assisted living folks who fall and bump their head or have real or false issues all the time. Anyway, it has taken her months to get the patient and their meds balanced and in order, get the staff at these places to finally carry out her plans properly, as well as have the family or the place go to one pharmacy to track and keep all their meds together and correct, and BAM one little ride to the ER or a day or two admit and all this hard work gets shot to hell! Then we are scrambling for days and weeks having long unpayed for phonecalls with all the players to get this patient straightened out again. Worse yet, we usually don't get the hospital notes sent to us for days if at all, the local hospitals especally a certain Catholic one, are just terrible in getting us notes in a timely fashion. Then the doc has to review all this stuff that some resident late at night screwed up, and again all uncompensated no less, to try and get this all fixed.

Now you want to let all the players and the patient go running a muck thru all of this? No way Jose. And again that is why having a private copy that is very "Unoffical and for Personal Use Only" may be OK, but with all the conflicts going down between players it would get ugly pretty fast....

BTW "G" since I'm not too sure how much you know about the business and legal side of all this. It does seem like your the tech support but not the practice manager at your wife's place; HIPAA only really clamped down on the provider side of your personal privacy, much of it loosened the reins on the government and the carriers so they could share your personal health information, your protected health information even more, mostly to be used against you the patient and the citizen as a comsumer of healthcare payments. We call it PHI now in this HIPAA age. Sorry if I'm talking down to you if you are in the loop on all of this. But in this age of all these players trying the darn level best to steal and use our PHI against us as patients and providers, you just can't get me to accept servers with everyone's PHI on it. I opt out...

HockeyRef, the problem with the flash drive is availability. What happens if Mrs. Smith is found unresponsive on a mall bench and does not have her flash drive?

No I'm not the practice manager, I manage the technology with ALL of it's requirements. I'm quite aware of HIPAA regulations and its requirements.

The point however is this, how many providers would be willing to put the systems in place to make a patient's record instantly available to other providers/facilities?

How many providers would be willing to take a call at 3:00AM saying John Smith has been in an accident and we need his records NOW!

What happens when a patient decides he does not or cannot see Dr. Gordon any longer, and he is switching to Dr. Martin? How does that "record transfer" take place?

I hear physicians complain every day about how much more paper work and regs they have to deal with...yet they want to volunteer to participate in an even more regulated enterprise: information management.
This, in my opinion, places an unnecessary burden on the provider.

Gee,
We get records requests from these carriers all the time and at least 50% of the time they are unfounded and not entitled to the information. They are simply trying to sneak out on paying your claim by pretending they have a reason like a pre-existing condition clause to fall back on. But I as the "human" in the middle, something you almost always can not replace with a preset set of rules and parameters, who knows the law and my patients, can flag this, warn the family, tell them what they need to say and do, the proof they need and things like that, and get us paid, and their claim paid for, all without allowing these invassive bozos into your charts and our wives charting history.

Understand that the more they see your wives charts, the more charting history they have on her and then it is only a matter of time that they use this collected data to start demanding give backs on a considerable amount of her submitted claims. This is what they are really doing. When they spy on the patient they are also spying on the doc and visa versa.

This is not just me and my Agent Mulder kind of X-Files conspirancy talk here, this is the official stance of the NYS Medical Society. They have paid a very well spoke and intelligent lawyer from a graet pro doctor firm, to go around the state to local societies and talk about this very subject. These are not simply for them to dot and I or cross a T here, these are called charting Audits and each and every time they get one that is exactly what they are doing. They are watching your wife's every single word for a little slip up that would then give them the excuse to come into your office and tear it limb to limb.

There are much bigger things at stake here besides simple access to a patients data in a time of emergency. Do you know how these things work when they go rummaging thru an office. Call your lawyer before you let them in, seriously. They request and pull charts in a totally non-random fashion, and then use this false and inappropriately sampled data to then make conclusions about all, yes ALL, the claims you have submitted over a multi-year period and then demand a give back of thousands of dollars, based on a few charts, that the data is in violation of standard practices of proper statisical rules. Yes they really use statisics that are based on data that was improper from the start. Only in this crazy upside down business could anyone even think no less do it. If our wives did research based on such inappropriate models their peer reviewed journals would run them out of town on a rail. But both the gov't and the private carriers are doing this as we speak to doctors each and every day and are getting away with it. Who has the financial resources to fight Aetna, UHC, CIGNA, BC/BS??? Not us....

And with the flash drive, why not have some revolving secert code that emergency workers and docs can use to access a patients data in a true emergency. And as I said before cover this access under the assumed consent laws just as we would if my wife found you unable to speak for yourself in a car accident. Yes, please save my life.

In any of you have kids then you should know the Pixar film, "The Incredibles". One of my favorite kids movies. Watch the scenes where Bob works at the insurance company and is getting chewed out by his boss because all of his patients know how to "penetrate the Beauacracy". This is what these SOB's really do all day long. And if you see Bob helping the poor old lady, "I'm not supposed to tell you to ask for form....." that is Village Medical and me the PM assisting our patients. We should never give up the human filter to run interference with these SOB's.

Like I said to you before, don't just give in to the hype (I know you actually know the tech behind it) don't be fooled by the cover story, especially the one they all throw out, about the unconscience car accident, it is but a smokescreen for what they really are after, all of our PHI to use against us and against our doctors. Please Protect Your Wife, Please. Things are never what they seem. You should know this after all the people they have killed and mamed in the name of corporate profits.

If you and I exchanged money in return for the physical harm of another human being the AG's of any state would come down on us like a pack of hungry wolves, as they should, for Rackteering, and this is what it is, but in the insurance game we simply turn a blind eye on it as business as usual. They are a cartel, that regularly practices Racketeering. No checks and balances on how they behave while they exchange money back and forth in exchange for the harm of others, profiting at the expense of the harm of another real live human being.

Should we really be trusting them with our wives' charting and our families' PHI??? Come on now.... You are way too intelligent for that.

have a great night, I really have to catch up around here.... Be well.
Paul

HockeyRef, I am not so naive to believe there are people out there with less than pure motives. My primary concern is who decides whose motives are pure...when in doubt "leave it to the patient."